Provider Demographics
NPI:1104019140
Name:FAMILY FIRST HEALTH CENTER PC
Entity Type:Organization
Organization Name:FAMILY FIRST HEALTH CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-310-1499
Mailing Address - Street 1:1632 LEBANON AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-2466
Mailing Address - Country:US
Mailing Address - Phone:618-310-1499
Mailing Address - Fax:
Practice Address - Street 1:1632 LEBANON AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-2466
Practice Address - Country:US
Practice Address - Phone:618-310-1499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1700902988OtherOWNERS NPI
IL1700902988OtherOWNERS NPI
ILV01690Medicare UPIN